What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

FEEDBACK,FEEDBACK,FEEDBACK! WRITE YOUR FEEDBACK ABOUT THIS BLOG, WHAT IS GOOD, POOR AND CONSTRUCTIVE SUGGESTIONS FOR IMPROVEMENT TO THIS FEEDBACK THREAD

Wednesday, January 09, 2008

Should Physicians Provide Information so Patients can Hasten Dying?

"Should Physicians Provide Information so Patients can Hasten Dying?" That is the question posed to me by Dr. Stanley Terman as a suggested title for a new blog thread. I thought it was an appropriate subject and invited him to write up the topic for posting. Stanley A. Terman, PhD, M.D . is a psychiatrist and Medical Director of Caring Advocates, an organization whose staff provides advice on creating and implementing Living Wills and Proxy Directives, advocating voluntary refusal of food and fluid, also providing advice on how to treat symptoms of dry mouth. His discussion of the issue follows, including an excerpt from his book entitled "The Best Way to Say Goodbye, A Legal and Peaceful Choice at the End of Life" written with Ronald B. Miller, MD, and Attorney Michael S. Evans.

I encourage my visitors to think about and perhaps write about the title's general question in terms of professional medical ethics but also consider the other more specific questions that Dr. Terman asks. ..Maurice.

Dr. Terman's Post to this Thread:

Physician Assisted Suicide (PAS) is illegal in the United States except in the state of Oregon. There, under strict guidelines, at the request of the terminally ill patient, the doctor can write a prescription for a lethal dose of a drug. Then, if the patient's suffering becomes unbearable, s/he can decide to ingest the medication (without help from others) to cause a peaceful dying. The physician would then have performed the act of writing a prescription, but would not be involved in administering the drug. Since writing the prescription is the legal proximate act that made hastening dying possible, people argue whether this act is ethical.

Since it is legally possible to hasten dying by Voluntary Refusal of Food & Fluid, this question arises: is it ethical for a physician to "inform" patients who would otherwise not be aware that it can be peaceful, especially if the physician provides Comfort Care to reduce the symptoms of dry mouth? The method suggested in the book is one of voluntary refusal of food and fluid, which mainly through dehydration will cause a peaceful death in a couple of weeks.

Suppose a patient is terminally ill, has no hope of recovery, and wants relief from prolonged pain and suffering.Suppose further the physician informs the patient that it will not be uncomfortable to refuse food and fluid since A) hunger is generally not a problem, and B) thirst is a symptom that can be treated. Suppose finally that divulging this knowledge tips the patient's decision who otherwise would NOT have done anything active to hasten the process of dying, but now will passively voluntarily refuse food and fluid.

Questions: Does the physician's act of informing the patient have the same moral effect as prescribing a lethal dose of pills, so this is really morally the same as physician-assisted suicide?Would withholding of this information be an example of "moral paternalism," and make the physician culpable for lack of informed consent and cruel for not giving the patient the choice to relieve his/her suffering when it was possible to do so?

Excerpt from pages 61-63 of The BEST WAY to Say Goodbye: A Legal Peaceful Choice at the End of Life:

Why might physicians be reluctant to educate and inform the public? In part,because of the controversy stirred by a few vocal doctors over whether or not it is morally right to inform patients of this option. Jansen and Sulmasy argued [2002] that if the patient or the physician believes that physician-assisted suicide is morally wrong, then it is also morally wrong for anyone to collaborate on any action that has an equivalent result. These authors also wrote it was morally wrong for doctors to inform patients about Voluntary Refusal of Food &Fluid (if the doctor thought it was morally wrong). Their article stimulated vehement disagreement in several letters subsequently published in the same journal.

Dr. Erich Loewy went one step further in 2001. He wrote that he could accept the practice of physicians who agreed to continue to care for patients who decided on their own to ask for Voluntary Refusal of Food & Fluid. But he used the word, "macabre," to describe informing patients about Voluntary Refusal of Food & Fluid when they "ask for help in ending their lives." His reason: that would be tantamount to "advising them to starve themselves," which he termed "physician-stimulated self-starvation." He argued that its real purpose was solely to "let health care professionals off the legal hook." To support his opinion, Loewy briefly reviewed the cultural benefits of food by noting it "symbolically representsour social acceptance and is an integral part of marriage, burial, and other social practices." He concluded that informing patients about Voluntary Refusal of Food & Fluid is "encouraging them to commit social suicide." Even worse: "To encourage them to stop eating and drinking before they truly wish to do so seems a cruel act of rejection." {Emphasis added.}

Certainly, Loewy is correct about the issue of timing: some patients do ask about Refusing Food & Fluid "before they truly wish to do so." Yet once informed, patients may feel reassurance in knowing they have the option to end their suffering at any future point in time. Obviously, they do NOT need to stop eating and drinking immediately after their doctors provide this information. In fact, one advantage of this method of dying is that patients can even decide to change their mind even after they stop eating and drinking by resuming intake.On the other hand, patients may feel abandoned by their physicians if their doctors refuse to offer information they are desperate to learn. This is especially true when patients ask about help in ending their lives.

Dr. Ira Byock [1995] wrote, "In my own practice, while I steadfastly refuse to write a prescription with lethal intent or otherwise help the patient commit suicide, I can share with the patient information that he or she already has the ability to exert control over the timing of death. Virtually any patient with far advanced illness can be assured of dying—comfortably, without any additional physical distress—within one or two weeks simply by refusing to eat or drink.This is less time than would be legally imposed by waiting periods of assisted suicide initiatives. The discussion and subsequent decision are wholly ethical and legal, requiring no mandated psychiatric evaluations,attorneys, court decisions, or legislation." {Emphasis added.}

A key question: How can people make prudent choices if they are not informed about the available options? Physicians who oppose disclosure may be worried about overly influencing their patient to choose Voluntary Refusal of Food &Fluid, which in their personal opinion, would be the "wrong" choice. But, we should ask, is not the withholding of relevant information from patients who directly request it, just one way for physicians to impose their personal values ontheir patients?

Graphic: Painting "The Death of Socrates" by Jacques-Louis David (1787) from the Metropolitan Museum of Art, New York, USA. (Socrates about to drink hemlock poison to carry out his suicide punishment.)

2 Comments:

I think the last part of the comment is on target. I realize it might seem like a unique situation because we're talking about dying, but isn't this pretty much like saying that as the doctor, you have decided which choice the patient should make, and you're going to encourage it to happen by selectively providing information steer them toward that choice? For example, I have seen some debate about how doctors should handle female patients who want to avoid having any children at all, when the doctor feels the patient is "too young" and "might change her mind later." A doctor in that situation could simply not tell am unaware woman that surgical sterilization is available and not very complicated. That seems to me not much different than not telling a dying patient all their options. You're just steering a patient toward your choice by filtering information. Is that ethical in other situations, or is there some difference with the dying patient?

How perceptive of you to compare the “filtering of information that doctors share with patients” to influence their choices -- at the end of life and at the beginning of life.

There is a significant difference, however: At the beginning of life, patients continue on with their lives so they can talk to other patients, think and learn about other options, and even become advocates for change. In contrast, the end of life is characterized as the last opportunity for others to help patients explore their options so they can determine what they really want and then for us to honor those wishes.--Stanley A. Terman, Ph.D., M.D.

The content of this blog is Copyrighted 2004-14. Maurice Bernstein, M.D. All Rights Reserved

FAIR USE NOTICE:

If this site contains copyrighted material the use of which has not been specifically authorized by the copyright owner, it is being made available in an effort to advance the understanding of the ethics dealing with medical practice, medical care, science and scientific research, human rights, social justice and, in addition, the law and politics which cover these areas. It is believed that this use constitutes a 'fair use' of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, the material on this site is distributed to visitors of this “Bioethics Discussion Blog” without profit to the blog or to those who by visiting this blog have expressed interest in receiving the included information for research and educational purposes. If you wish to use copyrighted material from this site for purposes of your own that go beyond 'fair use', you must obtain permission from the copyright owner.

The material in this site is provided for educational and informational purposes only, and is not intended to be a substitute for a health care provider's consultation. Please consult your own appropriate health care provider about the applicability of any opinions or recommendations with respect to your own symptoms or medical conditions. The information on this site does not constitute legal or technical advice.